RAC DIRECTORS´S LETTER
Health Strategies: From Medical Profession to Social Medicine*
Estrategias de salud: del oficio médico a la medicina social*
A BIT OF HISTORY
Although I will try to develop the new “health strategies” that come about in the passage “of the medical
profession”, which still has to be improved, “to social
medicine”, ideas stem from something, from someone
from somewhere; and specifically speaking, it is necessary to know the context in which I was born and developed, because as a political-philosopher and economist of the nineteenth century said: “the essence of
man are his social relationships”; or to quote a Senegalese proverb “if you want to know where you’re
going, turn around and see where you come from.”
In my adolescence, the most common means of
transportation was the electric tram (1), there were no
traffic lights and still at the intersection of Independencia and Pasco, where I lived, there was a post, with
a policeman who occasionally directed the traffic. The
houses remained with the doors open for residents to
come and go as they pleased, and people would take
their chairs and sit at the front door during the evening to chat with passing-by neighbors.
Of the current mass media there was only the
valve radio, which took a few minutes to start working, because it needed “to warm up” the circuit of
valves. It was a listening culture which stimulated our
imagination: the roaring of Fangio’s Maserati engines
turning the curve in front of Jose Elias Sojit’s post,
or the representations, also only listened, of classic
plays, broadcasted through Radio Nacional in “ LasDos Carátulas “, (The Two Cover Sheets).Television
only appeared in 1951 when I was already 10 years
old. On the threshold of the sixties we enjoyed the first
Japanese transistor radio, the famous SPICA (ST-600)
with leather case, which let young people listen to the
radio in the street, because its small size allowed the
widespread gesture of holding the speaker against the
ear with one hand ... although it came with a monaural headset that nobody used.
When I was almost 15 years old I attended the Casa
del Pueblo (People’s House) and bought a bound book
of the first volume of “Das Kapital” by Karl Marx,
translated by Juan B. Justo, with its pages scorched
by the intentional fire of the library, and I made the effort of trying to read it. About the same time a secondary school friend handed me a book of his grandfather;
it was Jack London’s novel “The Iron Heel”, of whom
I only knew the books about the wolfdog Klondike. I
was enormously impressed with its reading, with the
demolishing arguments of that worker called Everhard and the dystopian vision of class struggles to
death in the so-called “Chicago Commune”, with the
description of an oligarchy that the character called
the “iron heel “. The book published in 1907 heralded,
before the First World War, the development of fascism that would trigger the Second.
In June 1958, still with 16 years, I went on June
27th, for the first and only time, to the box of the
Chamber of Deputies to attend the derogation of the
infamous 4144 “residence act”. The law allowed during the state of siege to expel, without previous trial
and discretionally, the most conscientious and active
socialist and anarchist workers who disturbed the
conservative classes. The 4144 law was conceived and
promoted by Miguel Cané in 1902, the creator of the
autobiographical novel “Juvenilia” and was used in
the first national centennial of 1910 to dismantle the
labor movement that was preparing a counter parade
in front of the numerous foreign guests. That day of
1958, the UCRI block chaired by Gomez Machado
passed the 14445 law abolishing the residence act.
In the second half of that year the so-called Domingorena law originated the confrontation of ideas
of secondary and university students. There were two
groups, the “free” group, identified with a green ribbon, supporting private universities to issue certificates with no final exam at the public university and
the “laica” group identified with a violet ribbon who
opposed this idea.
Secondary schools boiled with public discussions,
multiple warnings and mimeographed pamphlets.
The “free” group made a massive demonstration on
September 15th at the front of Congress, with around
60,000 people. Four days later, the answer was a more
impressive demonstration of the “laica” group that
gathered around 300,000 people, and which I attended
but away from the official box, near Plaza Lorea, after
the arduous task of convincing my mother.
I could define myself as a man of the sixties; during
the first half of that decade I studied medicine at the
University of Buenos Aires (UBA), and in the second
half I did my medical clinical residency at CEMIC under the direction of the unforgettable Norberto Quir-
Rev Argent Cardiol 2015;83:362-371. http://dx.doi.org/10.7775/rac.v83.i4.6843
*Conference on June 16, 2015 upon receiving the declaration of Outstanding Personality of Sciences in the Field of Health from the Legislature of
the Autonomous City of Buenos Aires.
RAC DIRECTOR´S LETTER / Hernán C. Doval
no. In the late 60s I was already working full time and
starting the development of the new Coronary Care
Unit of Hospital Italiano de Buenos Aires (the second
in the country after that of Hospital Argerich) under
the leadership of its builder, Dr. Raúl Oliveri.
From my first wish to be a clinician, I then became
interested in the development of the new field of cardiac intensive care. After the initial decrease of AMI
deaths in the new Coronary Care Unit, the emergence
of the cardioverter defibrillator designed by Lown led
us to investigate how to promptly diagnose and quantify hemodynamic failure, in order to seek measures
that would reduce residual death due to pump failure.
It was already known that in the absence of pulmonary hypertension, pulmonary artery diastolic
pressure was equal to the “wedge pressure”, representing pulmonary capillary pressure (PCP). In turn,
an experimental small caliber “floating” catheter with
a thermistor to measure cardiac output, carried by
blood flow to the pulmonary artery had been developed at St. Thomas Hospital in London. We acquired
the equipment with the “floating” catheters, but their
positioning was extremely difficult and was even
worse under low cardiac output. So we developed,
with the indispensable technical assistance of my father, a mold to give a double curve to the terminal part
of a K-31 catheter, placing it in hot water and then
introducing a copper wire inside that came out at the
distal end with an outer ring that functioned as an
electrode-catheter and allowed its intracavitarian insertion under electrocardiographic control, finally to
be held loosely in one of the pulmonary artery branches. Its easy placement in the first or second attempt
was published in the RAC. (2)
With the emergence of catheters designed by Swan
Ganz with a distal inflatable balloon to measure PCP
and the subsequent addition of a thermistor to measure cardiac output by thermodilution, we were able to
build left ventricular pump function curves, with two
or more points of cardiac work against filling pressures, by decreasing venous return placing cuffs on
the extremities to reduce PCP, or increasing it with
volume expansion. The results were presented at the
Seventh World Congress of Cardiology held at the
Sheraton Hotel in Buenos Aires in September 1974.
Previously, on June 20th, 1973, although long since
a convinced Marxist, I was called to go as a cardiologist to receive, with an ambulance of Hospital Argerich, General Juan Domingo Perón who was definitely
returning to Argentina and would say a speech from
the last bridge, 3 km before the airport of Ezeiza, to a
gathering of about 3 million people on the highway. As
is known, I did not meet Peron but I was in the middle
of an intense firefight between security forces on the
bridge, led by Colonel Osinde and columns of Montoneros who came from behind, in what was called the
“Slaughter of Ezeiza”
When the coup of the genocidal dictatorship of
Videla-Viola takes place on March 24th, 1976, I sup-
363
ported the political line of the RCP (Revolutionary
Communist Party) and accepted immediately, without
a second thought, to be part of a clandestine cell of
physicians. All leaders remained in the country and,
contrary to the focalism of the guerilla, we kept from
the trenches the line of insurrectionary mass, the
distribution of the “Nueva Hora” newspaper and the
participation in such movements as rejecting a war
with Chile over the Beagle, alongside with the position of the Church.
As Pope Francis said, the RCP was the only party
that actively opposed the coup. Two days before the
coup the last letter of René Salamanca, general secretary of Córdoba SMATA was published in “Nueva
Hora” (3), flatly stating that: “I do not say that Isabel
has made no mistakes, I do not say that hers is the
best policy to confront imperialism. But I do say, that
she resists, struggles and tries not to surrender and,
in that sense, when those who want to overthrow her
are, as in 1955, the enemies of the country, her fall will
be a setback and a step forward of the super powers in
their conquering pursuit”. And he rightly adds: “Life
teaches us that just as there is no “good” imperialism,
there cannot be a “good”coup. The coup, whether proRussian or pro-yankee, has only one course in Argentina: popular super-exploitation, terrorist dictatorship,
delivery of national wealth and more hunger for the
popular sectors.” It ended: “I propose that the mechanic workers, as on many other occasions, be the vertebral column, the warlords and the unifying word of
the working class and the people of Córdoba against
imperialism, and particularly now, against the threatening Coup.”
In that period, although the development of the
pathophysiology of pump failure allowed us a better management of the acute phase, we found that
despite the response to potent vasodilators such as
prazosin increased cardiac output and decreased
filling pressures, a favorable outcome could not be
predicted in the long-term follow-up. We began to
acknowledge the need to prove the therapeutic measures pragmatically with long-term controlled clinical
trials. The publication in 1986 of Jay Cohn’s V-HeFT
I trial showed that the powerful drug prazosin did
not reduce mortality compared to placebo, perhaps
due to a tachyphylaxis mechanism. (4). In the same
year the streptokinase GISSI I trial versus control
in acute myocardial infarction appeared, that in addition to demonstrating the decline in mortality also
revealed the decrease of severe pump failure as a result of AMI size reduction. Moreover, the prevention
of pump failure was superior to the subsequent treatment of its pathophysiology.
Knowing that half of the deaths of patients with
heart failure were due to pump failure but that also
the other half died of sudden death from fatal ventricular arrhythmia, and acknowledging that Argentina had used amiodarone, a powerful antiarrhythmic
drug, for many years, we came up with the provoca-
364
tive idea of testing this drug, not studied previously in
clinical trials. It was used at low doses to prevent its
side effects, in ambulatory patients with severe heart
failure in a large, randomized, open, controlled clinical
trial (without placebo because we had none).
We formed a group of clinical researchers with cardiologists specialized in heart failure that we called
GESICA (Heart Failure Survival Study Group in Argentina) and the GESICA clinical trial was published
in 1994 in the English medical journal The Lancet; (5)
proving that amiodarone significantly reduced death
by 28% compared with the control group. However,
the reduction tendency was surprisingly similar both
for sudden death as death from progressive heart failure. The decrease in mortality and reduced hospitalization for heart failure was present in all subgroups
examined, and was also independent of the presence
or absence of non-sustained ventricular tachycardia in
the Holter at study inclusion.
In the post-hoc subgroup analysis published in Circulation, (6) non-sustained ventricular tachycardia in
a Holter study of patients with severe heart failure
was an independent mortality marker.
But even more important was the post-hoc publication, (7) showing that in the highest initial heart
rate quartile, the significant reduction of mortality
was higher, suggesting that the effect of amiodarone,
at least in part, was due to an inhibitory action on the
sympathetic system.
The latter assumption was confirmed in different
randomized clinical trials of beta-blocker effect, with
decreased mortality, both for the pump failure mechanism as for sudden death. Later, in the controlled trials
with implantable cardioverter defibrillators, overall
mortality was reduced by decreasing sudden death as
primary prevention in patients with severely impaired
left ventricular function (ejection fraction <35%).
The group of independent GESICA researchers,
turned into a foundation and continued performing
studies not attractive to pharmaceutical companies,
but of great interest to patients; for example phonecall follow-up performed by a nurse to monitor plans
and optimal treatment in patients with chronic heart
failure decreased by 28% the end point of death or
hospitalization for heart failure, which was maintained at long-term follow up after ending the intervention. (8) The leading cause of PAMI patients’
hospitalization is due to heart failure; however, even
though we offered our knowledge, experience and
advice free of all commercial interest, we could not
implement the program, which would have saved suffering to the elderly population and money to social
assistance.
In recent years, we tested the hypothesis that omega-3 fatty acids from fish oil would prevent recurrence
of symptomatic atrial fibrillation. (9) Although the
experience was negative, with this and other publications we conducted a meta-analysis that allowed us to
permanently cancel that research pathway.
ARGENTINE JOURNAL OF CARDIOLOGY / VOL 83 Nº 4 / AUGUST 2015
INFANT MORTALITY, OVERALL MORTALITY AND PREVENTION MODALITIES
In “health strategies” let us start by analyzing what
is considered the greatest achievement of the twentieth century, the worldwide reduction of mortality in
children less than 5 years of age. In the year 2000,
out of 130 million live births there were 10 million
deaths, which would have been 30 million deaths, 3
times more than the real figure, if the mortality rate
in Western Europe were that of the year 1900. But it
concealed that if the mortality rate of the rest of the
world were that of Western Europe in the year 2000,
the mortality rate would be about 1 million deaths.
Therefore, in our world today mortality is 10 times
higher due to the disparity of low- and middle-incomes
compared with high incomes. Children die according
to their class, as in the tragic Titanic deck.
In the autonomous city of Buenos Aires infant mortality rate is not uniform, it continuously increases its
toll from the lowest mortality in the North (Commune
14, Palermo), to the 2.2-fold highest mortality in the
South (Commune 4, Barracas, la Boca, Nueva Pompeya, Parque Patricios). In turn, the family income per
capita inversely decreases twofold and this would explain half of the increase in mortality (r2=0.49).
Our group analyzed the standardized rate of death
in people under 75 years of age (premature) and the
deprivation quintiles (percentage of unsatisfied basic
needs; the 1st. is the smallest and the 5th the largest)
in the 213 districts in which the country is divided,
from 2000 to 2011. (10) While there was a decrease in
mortality, it was more evident in the 1st quintile, increasing the inequality mortality dispersion by nearly
50% between the mortality in the lowest and highest
quintile. So inequality mortality rate openly increased
owing to the economic situation in Argentina.
What happened with the indicators of the National
Household Survey of CABA between 2003 and 2014
(12 years)? Owners of family houses declined steadily
from 2 out of 3 (64.4%) to nearly 1 out of 2 (54.7%),
1 in 10 families were no longer owners of their own
dwellings. This occurred although the level of tertiary
education also grew steadily from 1 out of 4 inhabitants (24.9%) to 1 out of 3 (34.3%) and care in the public health system gradually decreased from 24.8% in
2003 to 17.8% in 2014. Since 2008, under the management of engineer Mauricio Macri, no change has been
observed in these tendencies.
How can premature deaths be prevented? The
population, instructed by the media and advised by
doctors, believes that asymptomatic screening to detect early stage disease saves lives. But actually the review of all prevention studies in a meta-analysis of six
major diseases and 11 rigorously evaluated tests: abdominal aortic aneurysm: by ultrasound (n=86,449);
breast cancer: by mammography (good trials,
n=292,153), (mediocre trials, n=306,937) or self-examination (n=387,536); colorectal cancer: by occult
blood (n=328,642) or flexible sigmoidoscopy (n=not
RAC DIRECTOR´S LETTER / Hernán C. Doval
provided); lung cancer: by chest x-ray (n=81,303), xrays plus cytology (n=20,427) or CT scan (n=10,675);
ovarian cancer: by CA-125 (n=90,492); and prostate
cancer: by PSA (n=342,342) showed that although
abdominal aortic aneurysm by ultrasound, breast
cancer by mammography and colorectal cancer by occult blood and flexible sigmoidoscopy slightly diminish death due to the specific disease (death by aortic
rupture, breast cancer or colorectal cancer, respectively), none of the six diseases has evidenced significant
decrease in all-cause mortality. (11) In other words,
despite the huge cost invested in the latest technology, overall mortality cannot be reduced. The real disappointing conclusion is that screening does not save
lives.
So what should we do to prevent diseases that kill
people in the world today?
We have to admit that in our world people die as a
result of the products available on the market, manufactured by large dominant global corporations. Although there is the purpose of reducing mortality due
to smoking, all medical studies are devoted to addressing and modifying the host behavior ... but there are
almost no studies that recommend regulating corporations that produce the lethal agent. Jahiel proposes
to define a new category of “corporation diseases” as
“diseases of consumers, workers or community residents who have been exposed in the market, workplace
or community to disease agents contained in corporate
products”(12)
If we use the same epidemiological chain of classical
health, agent -vector- environment -host-, to characterize public health in the new era of corporations, for
example, smoking, we can assume that “cigarettes”
are the addictive and toxic causal agent (nicotine and
tar), but the vector are the large industrial corporations of the Big Tobacco companies seeking profit, the
environment are the receptive populations, currently
teens, women and especially developing countries, and
the final host is the cigarette consumer who becomes
addicted to a deadly toxic. To remove a biological epidemic like Chagas a campaign to eradicate its vector,
the Vinchuca bug, is necessary; likewise, in an industrial epidemic a regulatory campaign is also necessary
to finally eliminate the vector that is the Big Tobacco
companies producing the addictive and toxic agent.
If risk factors for chronic non-communicable diseases,
corresponding to two thirds of current mortality, respond to a “lifestyle”, we would talk and treat individual behaviors and blame the victim; for example,
those who smoke are not willing to quit (when we
know that he is an addict), turning the government,
industry and current structure of society invisible and
therefore acquitting them of their responsibilities.
To prevent the “lifestyle” metaphor from prompting
thoughts of individual responsibility, we really should
change the metaphorical expression and talk about
“way of life”, the sociological category that systematically reflects economic, socio-political and cultural
365
conditions which are the characteristic, stable and repeated ways of daily life of people and communities.
The “way of life” theory is based on the known concept of “mode of production” clearly defined by Marx
in the preface to A Contribution to the Critique of
Political Economy of 1859. In it he manifests “The
totality of these relations of production constitutes the
economic structure of society, the real foundation, on
which arises a legal and political superstructure and
to which correspond definite forms of social consciousness.” He proceeds with what is important to define
what we would call way of life. “The mode of production of material life conditions the general process of
social, political and intellectual life. It is not the consciousness of men that determines their existence, but
their social existence that determines their consciousness”. (13)
The epidemiologist Geoffrey Rose had already said in
the eighties. “It makes little sense to expect individuals to behave differently from their peers; it is more
appropriate to seek a general change in behavioral
norms and in the circumstances which facilitate their
adoption.” And he went on to say for the vast majority
of diseases “nature presents us with a process or continuum and not a dichotomy.”
This led him to one of the fundamental axioms in preventive medicine: “a great number of people exposed
to a small risk may generate many more cases than a
small number exposed to a high risk”
Therefore it is necessary to improve our understanding of how large industrial corporations (Big Tobacco,
Big Booze and Big Food) contribute to the disease
burden in two ways, directly through the promotion
of health-damaging products and indirectly by influencing public policy. Gilmore and colleagues say “The
concept of an industrial epidemic—an epidemic emerging from the commercialization of potentially healthdamaging products—lends itself to this purpose” (14).
And continued: “Indeed, the fiduciary responsibilities
of all corporations require them to maximize profits regardless of consequences to health, society, or the environment and thus to oppose policies that could reduce
their profits. There are, therefore, significant limits
to the compatibility of industry interests with public
health. Food companies, for example, have two basic
strategic options to enhance shareholder revenue: to
persuade consumers to eat more or to increase profit
margins. As much higher profits come from processed
compared to fresh foods, promoting the latter, advising
people to eat less or eat more healthily contradicts the
core business models of many food companies.”(14 )
To get acquainted with the subject, we need to know
that chronic diseases (cardiovascular disease, diabetes, cancer and respiratory disease) cause over 60%
(35 million) of all deaths worldwide; and over 80% of
these deaths occur in low- and middle-income countries. Merely from cardiovascular disease and diabetes 32%, 19 million subjects die; but the vast majority, 15 million die in developing countries. And what
366
is worse, at the same age, death is still 54% higher in
men and 86% higher in women than in high-income
countries. Therefore, this is our issue and not that of
the rich countries.
Since we have already exemplified with tobacco,
let us continue further on. About 1,300 million people
smoke, about 20% of the world population, but 80%
of smokers are in low- and middle-income countries.
Only Russia, Indonesia and China have 1 out of 2 of
the world cigarette smokers; the prevalence of tobacco
consumption in men is approximately 60%. Only in
China we find 1 out of 3 cigarette smokers. The media communicates that we are defeating the smoking
plague, but the projection indicates that there will be
over 1000 million deaths due to smoking at the end of
the twenty-first century. In contrast, in the twentieth
century 100 million people died. The media allied with
the large companies hide that there will be 10 times
more deaths in the new century.
To prevent a substantial proportion of the 450 million deaths by smoking before 2050 requires the cessation of adult smoking, a fact to which governments
and states around the world are very uncommitted;
since reducing the percentage of adolescents who start
smoking would only show the beneficial effect of reducing deaths from 2050 onwards. A few days ago the
newspapers commented that “Germany celebrated the
70th anniversary of the end of Nazism and its liberation.” We must remember that in the Second World
War conflict, between 1942 and 1945, about 24 million Soviets died and 70 years later, between 2011 and
2015, 24 million smokers died.
It is as if every day 17,000 passengers crashed and
died in 40 747 Boeing airplanes; in Argentina it would
represent a 747 Boeing plane-crash every 4 days.
Those who continue smoking compared with those
who never smoked double the increase in mortality; 1
of every 2 deaths is due to smoking and life expectancy
shortens in more than 10 years. (15)
With the production of cigarettes a “chain of eviction”
can be made. It is known that 1 ton of tobacco produces 1 million cigarettes, and these lead to 1 death;
in turn, 1 million-million cigarettes (i.e. 1 trillion) produces one million deaths; the current production of 6
million millions cigarettes (6 trillions per year) leads
to 6 million deaths (Figure 1).
The large tobacco companies’ profit was 50,000
million dollars in 2012; they thus earn almost 10,000
dollars for each death they cause.
How to stop this bleeding?; we know, through the
experiences of France and South Africa, that by increasing threefold the price of retail in a decade (with
real increases of 7% per year) reduces by half the consumption of cigarettes. Just by doubling the price of
cigarettes, by tripling the specific tobacco taxes, would
reduce its consumption to one third. (15)
Is it possible to reduce non-communicable disease
mortality by an active State policy? This goal could
be achieved if objectives such as reducing to <5% the
ARGENTINE JOURNAL OF CARDIOLOGY / VOL 83 Nº 4 / AUGUST 2015
smoking population and to <5 g salt intake (<2 g sodium) in the diet were established, and consumption were
reoriented placing taxes on junk food and sweetened
beverages and subsidizing fruits and vegetables (with a
neutral result for the State due to cross-linking), physical activity were promoted with special routes for locomotion and alcoholism were fought by raising the price
of alcoholic beverages. The cost of these interventions,
including the cost of drugs for persons at high risk for
cardiovascular disease for countries such as China, India and Russia, would range between 1.72 to 4.08 dollars per person per year. (16)
In Argentina there are approximately 300,000
deaths per year; nearly 2 out of every 3 deaths are
due to non-communicable diseases (almost 200,000
deaths): 32% owing to cardiovascular diseases and 3%
to diabetes; 22% to tumors and 7% to external causes.
(17)
If this program were followed, it is estimated that
the 35 million worldwide deaths from chronic diseases
would be reduced to 10.8 million, i.e. 31.2% of current
mortality (61.8% reduction). In Argentina, the nearly
200,000 deaths would be reduced to 63,000.
But these are only estimates and we should ask
ourselves the following question: is there evidence of a
fast fall of cardiovascular disease after abrupt changes
in the population “lifestyle”?
A REAL EXPERIENCE
A remarkable experience happened recently in Cuba
during the years called “Special Period”. Being under
THE CHAIN OF EVICTION
1 ton of tobacco
1 million cigarettes
1 death
1 million million cigarettes
(1 trillion)
1 million deaths
6 million million cigarettes
(6 trillions per year)
6 million deaths per year
367
RAC DIRECTOR´S LETTER / Hernán C. Doval
US embargo since 1960, after the implosion of the Soviet Union in 1989 Cubans had the added loss of trade
exchange (80%) and low-price oil from their Soviet
ally. At this time, they could not run buses and people
had to walk long distances to reach their jobs. Then,
Cuba bought a million bicycles from China and gave
them to the people for traveling. The “Special Period”
was almost an experimental situation of what happens to a population under these extreme conditions.
In that period, which started in 1989, the previous
calorie intake of 2,900 kcal in the average Cuban was
suddenly reduced to 1000 kcal (36% of calorie intake).
They were obliged to eat less food and make activities; the physically active population rose from 30%
to 70%. (18)
What happened with cigarettes? The number of
smokers continued to be the same, but as cigarettes
were a luxury article, they reduced by half the number of cigarettes smoked. Fortunately, the attitude of
smoking less persisted after Cuba recovered. And the
fact that they had bicycles preserved physical activity in 55% of the population. Thus, Cubans had some
good things left from that unfortunate period which
lasted until 1995.
What happened with the population’s average
weight? It was reduced in 5.5 kg (1.5 U of BMI) and
hence obesity was reduced by half, from 14% to 7.2%.
And what happened with diseases? It was a spectacular experiment; mortality for diabetes fell to 50%
in 5 years, 50%!
Deaths due to coronary artery diseases decreased
by 37%.
And cancers? Nothing happened, the percentage
was the same. All-cause mortality had dropped by
18%, mainly due to the reduction of coronary artery
disease.
After these relevant changes, can you imagine what
happened to Cubans when they recovered from the
“special period”? Recently, an international publication from the same group (19) showed what occurred
afterwards. Body weight progressively recovered after
the abrupt fall of the special period, increasing an average of 9.5 kg, over that of the initial weight. Hence,
the prevalence of diabetes accelerated proportionally
following the increase in body weight. The incidence
of diabetes which had fallen suddenly continued to increase to previous values.
What happened with mortality for diabetes? After
the peak drop of 51% it started to grow at a rate of
3.3% per year and by 2010 it had increased to 49%.
Coronary artery disease which had fallen by 35%,
6.5% per year, became stable again, with an annual
drop of 0.5% per year, similar to the previous period.
Cuba is an exceptional experiment regarding body
weight changes, with an abrupt decrease and then a
rebound in a very short period of time. This produced
a decrease in mortality for diabetes and coronary artery disease, which then increased again. Why do we
say it was due to body weight? Because the number
of cigarettes Cubans smoke today is the same as that
of the special period (<50% of the previous number
of cigarettes), and although the amount of exercise is
somewhat less, they perform more physical activity
than previously.
In situations in which structural conditions of life
change in a short period of time, 5 years, these changes
are closely followed by changes in non-communicable
disease mortality.
Then, seeing what happened in this natural experiment: could we purposely and conscientiously reduce
non-communicable diseases? Could an active State
and healthcare professional policy organize and promote these changes?
To achieve our medical function with each patient
we face, in addition to knowing the diagnosis, outcome
and treatment of their specific disease and having an
empathic and supportive relationship, we need to
know and modify the variables of their immediate environment, the community in which they live and the
State’s social and health policies, which constitute the
setting that many times determine their possibility of
life and development.
THE BEGINNING OF SOCIAL MEDICINE IN THE WORLD
AND ARGENTINA
To accomplish the role of medicine today would imply
creating a “social medicine”. Rudolph Virchow, in the
mid-XIX century, expressed simply and impressively
this concern about the associations of medicine with
social problems: “Medicine is a social science, and politics is merely medicine at a large scale”.
Virchow put into practice his convictions. Through
a letter addressed to his father, who must have been
very worried because he did not know where he was
at the time of the Berlin revolution, we know that
this 27-year old doctor who was privat dozent at the
Charité Hospital in that May of 1848, was in the barricade blocking the pass between Friedrich and Tauben streets, and wrote: “I have often been fooled by
people, but not yet with the era. As a result I have now
the advantage of not being a partial but a complete
person, and my medical principles agree with my political and social ideas”.
He simultaneously founded a newspaper called
“Medical Reform” and its pages advocated that the
State was responsible for the health of the Prussian
population and had the obligation of providing care,
with doctors who would be State officials, so that everyone would have the possibility of having medical attention. In addition, the State would have to make the
necessary structural changes to prevent epidemics, as
the sewage system in Berlin he personally promoted.
We will speak about the “Social medicine tradition in
Argentina”, recalling what Ramón Carrillo said: “It is
evident that today there can be no Medicine without
Social Medicine, -this he said in 1948- and that there
can be no Social Medicine without a State social policy”. He clearly saw what the problem was: there could
368
ARGENTINE JOURNAL OF CARDIOLOGY / VOL 83 Nº 4 / AUGUST 2015
be no medicine without it being a social medicine, but
at the same time, to achieve social medicine, there had
to be a State social policy.
Let us see how Carrillo understood medicine. To simplify, he created three terms to qualify Medicine. He
called our well-known “medical care”, “Archimedicine”, something similar to the first medicine; that is,
the microcosmos of the patient-doctor relationship,
which placed the patient and doctor as Robinsons in
an island, isolated from their social context.
The so-called “sanitary medicine”, where the State
appeared between the doctor and patient (trinomial),
was defined as “Paleomedicine”, old medicine, and he
placed it in the mesocosmos. That is, it belonged to a
larger context, but did not comprise all the structure
that produced disease.
And lastly, “social medicine”, where the community
was associated to the patient, doctor and State, was
called “Neomedicine”, the new medicine, which with
this tetranomial had a vision from the macrocosmos
to the microcosmos, passing through the mesocosmos.
He firmly stated “What is the importance for medicine
to scientifically solve the problems of a sick person, if
simultaneously there are hundreds of cases of sick people as a result of lack of food, anti-hygienic dwellings
–that are sometimes caves- or because they earn insufficient salaries to meet their needs?”
Since we are speaking of housing, let us analyze the
housing problem in the city of Buenos Aires. In the
second half of the XIX century, Frederich Engels already declared: “What today is understood as housing
shortage is the specific severity of the bad housing conditions of the workers as a result of the sudden rush of
the population towards the great cities, generating a
high increase in the rent, greater agglomeration of tenants in each house, and for some, the impossibility of
finding shelter. And this housing shortage gets talked
of so much because it affects not only the working class,
but also the lower middle class.” (20)
Table 1. Housing situation in CABA. Personal elaboration (with
data from reference 23)
Homes
Total
Definitions
All CABA homes
Without deficit Habitable dwellings with good
Number (n)
%
1,150,134
100
1,017,564
88.5
132,570
11.5
71,919
6.3
60,651
5.3
apartments and houses
With deficit
Unrecoverable or restorable houses
or densely-populated
accommodations
Quantitative
Live without dwelling, share
a dwelling or live in
unrecoverable house
Qualitative
Live in recoverable dwellings (6), or
densely-populated accommodations
(≥ 3 persons per room)
A similar phenomenon occurred in Argentina, wellillustrated by the classical work “Buenos Aires Del
centro a los barrios 1870-1910” (Buenos Aires From
downtown to the neighborhoods 1870-1910), where
the American writer James Scobie describes the
growth of the city and the migration of popular sectors from downtown to the peripheral neighborhood
at the turn of the XX century. (21)
The Autonomous City of Buenos Aires (CABA) ,
similar to other large cities of Argentina, has a profound housing crisis, with individuals without dwelling, whose only address is street situation (around
3,000 persons – approximately 2,200 sleeping in shelters and 800 in the street), or living in slums or piledup in precarious rooms (around 132,570 homes, 11.5%
of CABA homes).
The solution is to build “new houses” called “social
houses” –impossible to finance privately- because they
need the State’s help. In a city collapsed by the infrastructure of its public services of electricity, gas, water
and storm drainage system, is there not a more immediate solution?
Certainly, we all know there are empty habitable
houses which are not in offer. Could currently unoccupied houses in CABA that were somehow put to letsolve this pressing problem in a short time?
How could we know this? By looking at the 2010 National Population, Homes and Housing Census, whose
definitive data were published in 2012. (22) The almost 3 million CABA inhabitants (exactly 2,890,151
persons) should be distributed in the 1,425,840 dwellings registered in the census, but surprisingly, 340,975
houses are uninhabited. That is 23.9% is the bulky
percentage of empty houses; 1 out every 4 houses is
unoccupied!
In the impressive 40% empty dwellings in the
downtown Commune 1 (Retiro, San Nicolás, Puerto
Madero, San Telmo, Montserrat and Constitución) a
great deal will have to do the fact that the apartments
are offices. But 6 traditional residential districts have
more than 20% uninhabited dwellings, as Recoleta
(Commune 2) 34.7%, Palermo (Commune 14), 29.5%,
Nuñez, Belgrano and Colegiales (Commune 13) 24.6%,
Balvanera and San Cristóbal (Commune 3) 25.7%, Caballito (Commune 6) 21.9%, and Almagro and Boedo
(Commune 5) 21.0%. Five additional communes have
between 18 to 20% unoccupied dwellings and 3 communes less than 18%, including the Southern neighborhoods as La Boca, Barracas, Parque Patricios and
Nueva Pompeya (Commune 4) that have 16%.
Table 1 shows that from 1,150,134 CABA homes,
11.5% (132,570) are in a situation of housing shortage, because they do not have a dwelling, live in unrecoverable or restorable houses or in densely-populated
conditions with 3 or more persons per room, with a
slight predominance (6.3%, n=71,919) of homes without dwelling or that live in unrecoverable houses with
respect to those that live in precarious but potentially
restorable dwellings (5.3%, n=60,651).
RAC DIRECTOR´S LETTER / Hernán C. Doval
We therefore arrive to the conclusion that if there
are approximately 130,000 to 140,000 homes which
we can consider live in deficient conditions, and the
number of empty CABA dwellings is around 340,000,
we may say that the unoccupied dwellings that could
be offered, exceed 2.5 times the housing deficit; thus,
it would be possible to solve relatively quickly the
housing problem of the city of Buenos Aires.
Aren´t third parties also harmed when a house
built to be lived in is not used, and therefore impacts
on the development opportunities of the life cycle
and even the possibilities of life of others due to the
absence of healthy dwellings and essential sanitary
services? Because, as the WHO “Commission for the
social determinants of health” declares:… “a great
deal of the high load of disease that leads to an overwhelming loss of premature lives emerges from the
immediate and structural conditions in which people
are born, grow, live, work and become old.” (24)
Is it not fairer, economic and practical for society that
the State regulates the housing market and also the
land of the city of Buenos Aires, with measures of progressive taxes that could even reach expropriation,
to avoid “speculative retention”in a city in which the
only proposal has been to finance, execute and add
new buildings, when a quarter of its dwellings remain
“idle”?
Returning to our Ramón Carrillo, he certainly
had a clear idea that “health” depended on living and
working conditions, of the preventive concern of the
State and the healthcare conditions.
He thus understood that the measures adopted to
improve it should be integral; a “Health Plan” should
be designed comprising healthcare as well as preventive and also social measures.
He thought that a “Healthcare Program” should
be included in a “Health Plan”, previously adapted to
the particular conditions of the country and society.
In only 8 years (1946-1954), Ramón Carrillo
achieved a monumental work. He built 230 healthcare
centers for Hospitalization, 50 Specialized Health Institutes and 3,000 Health Centers, called “dispensaries” (today APS) (Primary Healthcare). In addition,
he created EMESTA (Especialidades Medicinales del
ESTAdo) (State Medical Specialties), the first national drug company. He revolutionized the installed
sanitary capacity; when he started in 1946 there were
66.300 hospital beds, and when he left in 1954 there
were 134,000, more than double. He was our first Minister of Health and perhaps the last fit for that office.
PRESENT SITUATION AND OUTLINE OF SOME SOLUTIONS
How are we now? Argentina has a health expenditure
of 658 dollars per capita, 28% of which is dedicated to
drugs (U$S 186). It is the highest of Latin America,
only comparable to that of Uruguay (U$S 653); in
Chile (U$S 336), Costa Rica (U$S 273), Brazil (U$S
267) and Venezuela (U$S 233) the spending is less
than half.
369
The cost of the Public Health System is approximately one fifth of the total expenditure (21.5%); Social Security provides less than one third (30.3%) and
people´s pocket bears almost half (48.2%) of the total
health cost. (25)
Ten percent of the GDP is dedicated to health:
2.19% is provided by the State, 3.09% by Social Security and almost half (4.92%) is borne by the public,
concentrated in persons with high income (11.2%) and
decreasing to half in those with medium (4.5%) and
low income (5.3%). (26)
Where the money to finance healthcare goes is important in the improvement of mortality indexes, as
there seems to be a difference in mortality according
to where healtcare expenditure is increased in the longitudinal data of 153 countries.
If Public Health spending is increased 10% per
capita, mortality in children under 5 years of age decreases 7.9‰ and adult mortality drops 1.3‰. But if
the increase is in Private Healthcare Insurance, there
is no effect in mortality for children under 5 years as
well as for adult mortality. And if the 10% increase
comes from people’s pockets, the mortality of adult
women increases 11.6‰.(27)
A recent study analyzed the effect of the financial healthcare coverage in 89 low and middle income
countries during the period 1995-2011. (28)
An initial question is whether tax revenue was positively associated with public health spending. A crosssection of the 89 countries evidences a high direct correlation (r=0.91; p<0.0001, and 83% (r2=0.83) of the
increase in public health spending (per capita, and at
constant price) is associated with the increase in tax
revenue (per capita and at constant price).
They then ask what effect 100-dollar increase
per capita coming only from taxes or included in the
GDP (the spilling theory) has on public or private
health spending between 1995 and 2011. In the tax
increase, almost 10% (9.86%) is dedicated to public
health and none to private health; on the contrary,
a similar 100-dollar increase in the GDP produces
a similar small increase (around 2%) both in public
and private health. The following question is whether
it is the same that the increase in health spending
comes from direct progressive taxes (income, rent and
capital earnings) or from indirect regressive taxes to
consumption (goods and services). Only the 100-dollar growth in rent and capital earning taxes increases
public health spending by almost 17% (U$S 16.71),
not taxes on goods and services or other taxes that
do not increase health spending but tend to reduce it.
When asked: how does 100-dollar increase in taxes
or GDP affect the processes of healthcare and coverage? It is clearly shown that the increase in tax revenue raises prenatal coverage (6.7%), newborn care
(5.25%) and health coverage (11.35%), whereas the
increase in GDP has no effect on these parameters.
In turn, the increase in indirect taxes (regressive)
for goods and services, significantly enhances neonatal
370
(0.10‰), postnatal (0.17‰) and children under 5
years of age (0.43‰) mortality.
We can conclude from this analysis that tax increase enhances public and not private health spending when they are applied to rent and capital earnings, and that the isolated proportional increase in
GDP income does not increase public health spending
and to a small degree raises that of private health.
On the other hand, the increased income through
rent and capital earning taxes increases prenatal coverage, newborn care and health coverage. Regarding
mortality, the regressive income increase through taxes to goods and services promotes neonatal, postnatal
and children under 5 years of age mortality (28), as
well as that of adult women. Conversely, 10% increase
of public spending in health (per capita) decreases
mortality in children under 5 years of age and adults.
Let us then turn to medical coverage in the City of
Buenos Aires. Although from the overall population,
only 17.8% have public health coverage, 44.4% social
security coverage and 37.9% medical insurance (prepaid medical coverage), according to the last annual
2014 CABA household survey, the Southern, Downtown and Northern parts of the city of Buenos Aires
have very dissimilar health coverage, constituting
three cities within the same city.
In the Northern part of the city, with a population
of high and middle-high income, most people have
healtcare insurance (60.3%), a third social security
(35.6%) and public health coverage alone is almost
inexistent (4.1%). Conversely, in the South, with middle and low income inhabitants, a third of the population (31.2%) has only public health coverage, almost
half social security (48.4%) and only one-fifth (20.3%)
healthcare insurance. Downtown inhabitants have
health coverage similar to the city average.
Finally, we could say that a “Healthcare Plan” for
CABA as Ramón Carrillo wished, must also have the
best healthcare services, preventive action by the city
government and lastly the social participation of the
community.
Although the city covers all its inhabitants, albeit with
deep deficiencies in hospitalization and emergency, in
the strictly care assistance it should design a “Program of Ambulatory Medical Care” of excellence for
the complete coverage of the 3 million CABA inhabitants, creating groups of “ambulatory medical care” to
cover primary healthcare and prevalent specialties.
The total cost would not exceed $1,500 million pesos, financed by direct city taxes; it would cost $41 for
each of the 3 million inhabitants per month ($124 million per month). A unit of 1,200 inhabitants would be
covered by a healthcare group consisting of 1 general
practitioner, family doctor or pediatrician (a total of
2,500 physicians with a monthly income of $30,000),
1 nurse to control chronic diseases (hypertension, diabetes, etc.) (2,500 with a monthly income of $15,000),
2 community healthcare agents, trained from the
population without work, who would go periodical-
ARGENTINE JOURNAL OF CARDIOLOGY / VOL 83 Nº 4 / AUGUST 2015
ly to the home or the doctor’s office to educate and
control preventive measures (5,000 with a monthly
income of $7,500), 1 coordinating physician every 10
primary care physicians (250 with a monthly income
of $30,000) and 1 specialist every 20 primary care physicians (125 with a monthly income of $30,000).
The primary care physician would work 48 hours
per week. The direct care of patients, coordinating the
assistant nurse and the two community healthcare
agents, would be done during 6 hours per day, 4 days
a week. The 6-hour free day would be dedicated for
face to face consultation with specialists, allowing better medical education, which is education in service.
They would have 10 free hours per week (2 hours per
day) for direct interconnection with the coordinators,
who would update and standardize regulations, and
perform quality control and care research.
This would satisfy patients, who would always
have someone to consult (healthcare agent, nurse or
physician), avoiding visits to the emergency room, unless for a real urgent situation, and the subsequent
peripatetic medications prescribed by “anonymous”
physicians who do not know the patient.
It would also satisfy the system agents, who could
work and interact in a single healthcare environment,
avoiding multiple and unsatisfactory jobs to achieve
a decent income for living and fulfilling the goal of
feeling useful in the profession, with the possibility
of updating knowledge and perform clinical and community research to answer questions of interest to
patients.
Only thus will the healthcare professionals feel they
are fully using their capacity for those who need them.
Making real the future of a supportive community, in
agreement with Marx’s unforgettable phrase “…society will be able to write in its banner: from each according to his ability, for each according to his need”. (29)
Dr. Hernán C. DovalMTSAC
Director of the Argentine Journal of Cardiology
REFERENCES
1. Werckenthien CG. El Tranvía en Buenos Aires. 1.ª ed. Buenos Aires: Turísticas; 2007.
2. Doval H, Bazino O, Oliveri R. Un nuevo catéter para la medición
de las presiones pulmonares. Rev Argent Cardiol 1975;43:310-4.
3. Salamanca R. A los compañeros mecánicos. Nueva Hora 16 al 22
de marzo 1976.
4. Cohn JN, Archibald DG, Ziesche S, Franciosa JA, Harston WE,
Tristani FE, et al. Effect of vasodilator therapy on mortality in chronic
congestive heart failure: results of a Veterans Administration Cooperative Study. N Engl J Med 1986;314:1547-52. http://doi.org/c8469r
5. Doval HC, Nul DR, Grancelli HO, Perrone SV, Bortman GR, Curiel R. Randomised trial of low-dose amiodarone in severe congestive
heart failure. Lancet 1994;344:493-8. http://doi.org/b2s5v9
6. Doval HC, Nul DR, Grancelli HO, Perrone SV, Varini SD, Soifer S,
et al. Non-sustained ventricular tachycardia in severe heart failure.
Circulation 1996;94:3198-203.http://doi.org/56n
7. Nul DR, Doval HC, Grancelli HO, Perrone SV, Varini SD, Soifer
S, et al. Heart rate is a marker of amiodarone mortality reduction
in severe heart failure. J Am Coll Cardiol 1997;29:1199-205. http://
doi.org/d75752
RAC DIRECTOR´S LETTER / Hernán C. Doval
8. GESICA Investigators. Randomised trial of telephone intervention in chronic heart failure: DIAL trial. BMJ 2005;331:425-9. http://
doi.org/fbqt4c
9. Macchia A, Grancelli H, Varini S, Nul D, Laffaye N, Mariani J, et
al. Omega-3 fatty acids for the prevention of recurrent symptomatic atrial fibrillation. Results of FORWARD trial. J Am Coll Cardiol
2013;61:463-9. http://doi.org/kxq
10. Macchia A, Mariani J, Doval HC, Tognoni G. Socio economic differences, inequalities and avoidable deaths in Argentina: A countrywide, longitudinal (2000-2011) epidemiological profile (in press?).
11. Saquib N, Saquib J, Ioannidis JPA. Does screening for disease save
lives in asymptomatic adults? Systematic review of meta-analyses and
randomized trials. Int J Epidemiol 2015:1-14.http://doi.org/56p
12. Jahiel RI. Corporation-induced diseases, upstream epidemiologic
surveillance, and urban health. J Urban Health 2008;85:517-31.
http://doi.org/cdr5vt
13. Marx K. Prólogo a la Contribución a la Crítica de la Economía
Política(1859). En: Introducción general a la Crítica de la Economía
Política/1857. Cuadernos de Pasado y Presente; 1987.
14. Gilmore AB, Savell E, Collin J. Public health, corporation and
the new responsibility deal: promoting partnership with vectors of
disease? J Public Health 2011;33:2-4.http://doi.org/c7pvkk
15. Jha P, Phil D, Peto R. Global effects of smoking, of quitting, and
of taxing tobacco. N Engl J Med 2014;370:60-8. http://doi.org/4mk
16. Capewell S, O’Flaherty M. Rapid mortality falls after risk-factor changes in populations. Lancet 2011;378:752-3. http://doi.org/
bb4hgm
17. Aportes para el Desarrollo Humano en Argentina / 2011. OPS,
CEPAL, PNUD, 16/11/2011.
18. Franco M, Orduñez P, Caballero B, Tapia Granados JA, Lazo
M, Bernal JL, et al. Impact of energy intake, physical activity, and
371
population-wide weight loss on cardiovascular disease and diabetes
mortality in Cuba, 1980-2005. Am J Epidemiol 2007;166:1374-80.
http://doi.org/bjzg25
19. Franco M, Bilal U, Orduñez P, Benet M, Morejón A, Caballero B,
et al. Population-wide weight loss and regain in relation to diabetes
burden and cardiovascular mortality in Cuba 1980-2010: repeated
cross sectional surveys and ecological comparison of secular trends.
BMJ 2013;346:f1515.
20. Engels F. La guerra de campesinos en Alemania y El problema de
la vivienda. Buenos Aires: Editorial Claridad; 1971.
21. Scobie J. Buenos Aires. Del centro a los barrios 1870 - 1910. Buenos Aires: Solar Ediciones; 1986.
22. http://www.buenosaires.gob.ar/areas/hacienda/sis_estadístico/
censo_datdef/cuadros_viviendas.php
23. Centro de Investigación de Política Urbana y Vivienda (CIPUV
de la Universidad Torcuato Di Tella.
24. Marmot M, Friel S, Bell R, Houweling TA, Taylor S. Closing the
gap in a generation: health equity through action on the social determinants of health. Lancet 2008;372:1661-9. http://doi.org/d7krt8
25. Fuente Key Market sobre datos del Banco Mundial.
26. Aportes para el Desarrollo Humano en Argentina / 2011. OPS,
CEPAL, PNUD, 16/11/2011.
27. Moreno-Serra R, Smith PC. Does progress toward universal
health coverage improve population health? Lancet 2012;380:91723. http://doi.org/jbw
28. Reeves A, Gourtsoyannis Y, Basu S, McCoy D, McKee M, Stuckler D. Financing universal health coverage effects of alternative tax
structure on public health systems: cross-national modelling in 89
low-income and middle-income countries. The Lancet 2015;386:27480. http://doi.org/6wc.
29. Marx C. Crítica del Programa de Gotha. Editorial Anteo; 1972.